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Background
Information
on the Key International Agreements
The Convention on the Elimination of all forms of Discrimination against Women (CEDAW), which was adopted in 1979 and entered into force in 1993, condemns any form of gender discrimination, including discrimination in the field of health care resulting in unequal access to services. It calls on governments to ensure equal access to all health care services, including family planning and services related to pregnancy, delivery and postnatal care.
In 1987 the World Bank, in collaboration with WHO and UNFPA, sponsored a conference on safe motherhood in Nairobi to help raise global awareness about the impact of maternal mortality and morbidity. The conference launched the Safe Motherhood Initiative, an international call to action to reduce maternal mortality and morbidity by one half by the year 2000.
The work of UNFPA is guided by the Programme of Action that was endorsed by 179 countries in Cairo at the 1994 International Conference on Population and Development (ICPD). The Programme of Action identified maternal morbidity and mortality as important programme areas, and set targets for reductions in maternal mortality.
Adopted at the 1995 Fourth World Conference on Women, the Beijing Platform and Programme of Action affirms reproductive health as a human right and calls on governments to ensure equal access to health services, including family planning and emergency obstetric care. Beijing+5 was a special session held by the General Assembly in 2000 to reaffirm commitment to the principles set forth in the Beijing Platform and to determine priorities for future action.
Progress and challenges in the first five years of implementing the Cairo agreement were the focus of a series of meetings leading up to special session of the United Nations General Assembly (ICPD+5) in June 1999. The session identified Key Actions for the Further Implementation of the ICPD Programme of Action, including new benchmark indicators of progress in maternal mortality [para 64].
In 1997, ten years after the launch of the Initiative, a Safe Motherhood technical consultation took place in Colombo, Sri Lanka. Its goal was to review key lessons learned from the Initiative's first ten years and articulate a clear consensus on the most effective strategies and ways to implement these strategies at the country level. Key messages on reducing maternal mortality included:
- Recognizing that every pregnancy faces risks.
- Increasing access to family planning services.
- Improving the quality of antenatal and postpartum care.
- Ensuring access to essential obstetric care (including postabortion care)..
- Expanding access to midwifery care in the community.
- Training and deploying appropriate skilled health personnel (such as midwives).
- Ensuring a continuum of care connected by effective referral links, and supported by adequate supplies, equipment, drugs, and transportation.
- Reforming laws to expand women's access to health services and to promote women's health interests.
In 1999, using the lessons learned since 1987, WHO, UNFPA, UNICEF and the World Bank issued a joint statement that is now the basis of the consensus on:
- Prevention and management of unwanted pregnancy and unsafe abortion
- The need for every woman to have skilled care in pregnancy and childbirth, and
- The importance of access to referral care when complications arise.
In 2000, the member states of the United Nations unanimously adopted the Millennium Declaration, from which were derived eight Millennium Development Goals (MDGs) that serve as guide for development efforts. MDG 5 is an explicit call for to improve maternal health. It calls for a reduction by three-quarters, between 1990 and 2015, of the maternal mortality ratio. The percentage of births with a skilled attendant is one of the indicators used to measure progress toward this goal.
At the 2005 World Summit, the largest-ever gathering of world leaders committed themselves to achieving universal access to reproductive health by 2015. This is reflected in paragraph 57(g) of the World Summit Outcome document.
ICPD Programme of Action para 8.22 All countries, with the support of all sections of the international community, must expand the provision of maternal health services in the context of primary health care. These services, based on the concept of informed choice, should include education on safe motherhood, prenatal care that is focused and effective, maternal nutrition programmes, adequate delivery assistance that avoids excessive recourse to caesarean sections and provides for obstetric emergencies; referral services for pregnancy, childbirth and abortion complications; post-natal care and family planning. All births should be assisted by trained persons, preferably nurses and midwives, but at least by trained birth attendants. The underlying causes of maternal morbidity and mortality should be identified, and attention should be given to the development of strategies to overcome them and for adequate evaluation and monitoring mechanisms to assess the progress being made in reducing maternal mortality and morbidity and to enhance the effectiveness of ongoing programmes. Programmes and education to engage men's support for maternal health and safe motherhood should be developed.
ICPD Programme of Action para 8.21 Countries should strive to effect significant reductions in maternal mortality by the year 2015: a reduction in maternal mortality by one half of the 1990 levels by the year 2000 and a further one half by 2015. The realization of these goals will have different implications for countries with different 1990 levels of maternal mortality. countries with intermediate levels of mortality should aim to achieve by the year 2005 a maternal mortality rate below 100 per 100,000 live births and by the year 2015 a maternal mortality rate below 60 per 100,000 live births. Countries with the highest levels of mortality should aim to achieve by 2005 a maternal mortality rate below 125 per 100,000 live births and by 2015 a maternal mortality rate below 75 per 100,000 live births. However, all countries should reduce maternal morbidity and mortality to levels where they no longer constitute a public health problem. Disparities in maternal mortality within countries and between geographical regions, socio-economic and ethnic groups should be narrowed.
ICPD + 5 Key Actions para 62 Governments, with the increased participation of the United Nations system, civil society, including non-governmental organizations, donors and the international community, should: (a) Recognize the linkages between high levels of maternal mortality and poverty and promote the reduction of maternal mortality and morbidity as a public health priority and reproductive rights concern; (b) Ensure that the reduction of maternal morbidity and mortality is a health sector priority and that women have ready access to essential obstetric care, well-equipped and adequately staffed maternal health-care services, skilled attendance at delivery, emergency obstetric care, effective referral and transport to higher levels of care when necessary, post-partum care and family planning. In health sector reform, the reduction of maternal mortality and morbidity should be prominent and used as an indicator for the success of such reform; (c) Support public health education to create awareness of the risks of pregnancy, labour and delivery and to increase the understanding of the respective roles and responsibilities of family members, including men, as well as of civil society and Governments, in promoting and protecting maternal health; (d) Develop appropriate interventions, beginning at birth, to improve the nutritional, health and educational status of girls and young women so that they are better able to make informed choices at maturity about childbearing and obtain access to health information and services; (e) Implement programmes to address the negative impact of environmental degradation, in some regions, on the high levels of maternal mortality and morbidity.
ICPD + 5 Key Actions para 64 In order to monitor progress towards the achievement of the Conference's goals for maternal mortality, countries should use the proportion of births assisted by skilled attendants as a benchmark indicator. By 2005, where the maternal mortality rate is very high, at least 40 per cent of all births should be assisted by skilled attendants; by 2010 this figure should be at least 50 per cent and by 2015, at least 60 per cent. All countries should continue their efforts so that globally, by 2005, 80 per cent of all births should be assisted by skilled attendants, by 2010, 85 per cent, and by 2015, 90 per cent.
ICPD + 5 Key Actions para 66 The World Health Organisation in co-operation with other relevant United Nations bodies is urged to fulfil its leadership role within the United Nations system in assisting countries, in particular developing countries, to put in place standards for the care and treatment for women and girls that incorporate gender-sensitive approaches and promote gender equality and equity in health-care delivery and to advise on functions that health facilities should perform to help guide the development of health systems to reduce the risks associated with pregnancy, taking into consideration the level of development and the economic and social conditions of countries. At the same time, United Nations agencies, including the United Nations Population Fund and the United Nations Children's Fund, and multilateral development banks, such as the World Bank, should intensify their role in promoting, supporting, advocating for and investing in action to improve maternal health.
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ICPD Programme of Action para 8.21 Countries should strive to effect significant reductions in maternal mortality by the year 2015: a reduction in maternal mortality by one half of the 1990 levels by the year 2000 and a further one half by 2015. The realization of these goals will have different implications for countries with different 1990 levels of maternal mortality. countries with intermediate levels of mortality should aim to achieve by the year 2005 a maternal mortality rate below 100 per 100,000 live births and by the year 2015 a maternal mortality rate below 60 per 100,000 live births. countries with the highest levels of mortality should aim to achieve by 2005 a maternal mortality rate below 125 per 100,000 live births and by 2015 a maternal mortality rate below 75 per 100,000 live births. However, all countries should reduce maternal morbidity and mortality to levels where they no longer constitute a public health problem. Disparities in maternal mortality within countries and between geographical regions, socio-economic and ethnic groups should be narrowed.
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ICPD Programme of Action para 8.24 All countries should design and implement special programmes to address the nutritional needs of women of child-bearing age, especially those who are pregnant or breast-feeding, and should give particular attention to the prevention and management of nutritional anaemia and iodine-deficiency disorders. Priority should be accorded to improving the nutritional and health status of young women through education and training as part of maternal health and safe motherhood programmes. Adolescent females and males should be provided with information, education and counselling to help them delay early family formation, premature sexual activity and first pregnancy.
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ICPD Programme of Action para 8.26 Programmes to reduce maternal morbidity and mortality should include information and reproductive health services, including family-planning services. In order to reduce high-risk pregnancies, maternal health, and safe motherhood programmes should include counselling and family planning information.
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ICPD + 5 Key Actions para 65 In order to have a basis for cost-benefit analysis for interventions aimed at reducing maternal mortality, the societal costs of maternal deaths should be calculated. This should be done in co-operation among Governments, United Nations agencies and development banks, and the research community.
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ICPD Programme of Action para 8.25 In no case should abortion be promoted as a method of family planning. All Governments and relevant intergovernmental and non-governmental organizations are urged to strengthen their commitment to women's health, to deal with the health impact of unsafe abortion as a major public health concern and to reduce the recourse to abortion through expanded and improved family-planning services. Prevention of unwanted pregnancies must always be given the highest priority and every attempt should be made to eliminate the need for abortion. Women who have unwanted pregnancies should have ready access to reliable information and compassionate counselling. Any measures or changes related to abortion within the health system can only be determined at the national or local level according to the national legislative process. In circumstances where abortion is not against the law, such abortion should be safe. In all cases, women should have access to quality services for the management of complications arising from abortion, post-abortion counselling, education and family-planning services should be offered promptly, which will also help to avoid repeat abortions.
ICPD + 5 Key Actions para 63 (i) In no case should abortion be promoted as a method of family planning. All Governments and relevant intergovernmental and non-governmental organisations are urged to strengthen their commitment to women's health, to deal with the health impact of unsafe abortion as a major public-health concern and to reduce the recourse to abortion through expanded and improved family planning services. Prevention of unwanted pregnancies must always be given the highest priority and every attempt should be made to eliminate the need for abortion. Women who have unwanted pregnancies should have ready access to reliable information and compassionate counselling. Any measures or changes related to abortion within the health system can only be determined at the national or local level according to the national legislative process. In circumstances where abortion is not against the law, such abortion should be safe. In all cases, women should have access to quality services for the management of complications arising from abortion. Post-abortion counselling, education and family planning services should be offered promptly, which will also help to avoid repeat abortions. (ii) Governments should take appropriate steps to help women avoid abortion, which in no case should be promoted as a method of family planning, and in all cases provide for the humane treatment and counselling of women who have had recourse to abortion. (iii) In recognising and implementing the above, and in circumstances where abortion is not against the law, health systems should train and equip health-service providers and should take other measures to ensure that such abortion is safe and accessible. Additional measures should be taken to safeguard women's health.
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